Moda Pioneer Silver 4500 – PPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	PPO
Deductible	$250 per person $250 per person
Out-of-pocket max	$500 per person $1,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$10 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	$40 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	$60 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$10 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.modahealth.com/-/media/modahealth/shared/plans/AK/2024/individual/Moda-Pioneer-Silver-4500-CSV3-SBC-2024-AK.pdf
Drug and medication plan formulary	https://www.modahealth.com/pdl
Search doctor list	https://www.modahealth.com/shop/provider-search/medical/ak/Pioneer